mental health vs work

8/21/2019 mental health vs work

1/77

NATIONS

FOR

MENTAL

HEALTH

M e n ta l h e a ltha n d w o rk :

Im p a c t , is su e s a n dg o o d p ra c t ic e s

Ta r g e t G r o u p U n it

In F o c u s P r o g r a m o nK n o w l e d g e , S k i l l s a n d E m p l o y a b i l i t y

I n t e r n a t io n a l L a b o u r O rga n i s a t io n

M e n t a l H e a l th P o lic y a n d S e r v ic e D e v e lo p m e n tD e p a r tm e n t o f M e n t a l H e a l t ha n d S u b s t a n ce D e p e n d e n c eN o n c o m m u n i c a b le D i se a s e s a n d M e n t a l H e a l t h

W o r ld H e a lth O rg a n iz a t io n

G e n e v a

2 0 0 0


2/77

Mental health policy and service development team

Objectives and strategies

• To strengthen mental health policies, legislation and plans through: increasing

awareness of the burden associated with mental health problems and the commitmentof governments to reduce this burden; helping to build up the technical capacity of countries to create, review and develop mental health policies, legislation and plans;and developing and disseminating advocacy and policy resources.

• To improve the planning and development of services for mental health through:strengthening the technical capacity of countries to plan and develop services;supporting demonstration projects for mental health best practices; encouragingoperational research related to service delivery; and developing and disseminatingresources related to service development and delivery.

Financial support is provided from the Eli Lilly and Company Foundation, the Johnson andJohnson European Philanthropy Committee, the Government of Italy, the Government of Japan, the Government of Norway, the Government of Australia and the BrocherFoundation.

Further information can be obtained by contacting:

Dr Michelle Funk

Mental health policy and service development (MPS)Department of Mental Health andSubstance Dependence (MSD)World Health OrganizationCH - 1211 Geneva 27, SwitzerlandE-mail: [email protected]: (41) 22 791 3855Fax: (41) 22 791 41 60


3/77

NATIONS

FOR

MENTAL

HEALTH Mental healthand work:

Impact, issues andgood practicesGaston HarnoisPhyllis Gabriel

Mental Health Policy and Service DevelopmentDepartment of Mental Healthand Substance DependenceNoncommunicable Diseases and Mental Health

World Health Organization

Target Group UnitInFocus Program on

Knowledge, Skills and Employability

International Labour Organisation

Geneva2000


4/77

WHO Library Cataloguing-in-Publication Data

Harnois,Gaston.Mental health and work : impact, issues and good practices / Gaston Harnois, Phyllis Gabriel.

(Nations for mental health)

1.Mental health 2.Workplace 3.Mental disorders - therapy 4.Mental health services - standards5.Occupational health services - standards 6.Benchmarking 7.Cost of illnessI.Gabriel,Phyllis. II.Title III.Series

ISBN 92 4 159037 8 (NLM classification: WA 495)ISSN 1726-1155

This publication is a reprint of material originally distributed as WHO/MSD/MPS/00.2

This publication is a joint product of the World Health Organization and the

International Labour Organisation.

© World Health Organization 2002

All rights reserved. Publications of the World Health Organization can be obtained from Marketing

and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel:

+41 22 791 2476; fax: +41 22 791 4857; email: [email protected]). Requests for permission to

reproduce or translate WHO publications – whether for sale or for noncommercial distribution –

should be addressed to Publications, at the above address (fax: +41 22 791 4806; email:

[email protected]).

The designations employed and the presentation of the material in this publication do not imply theexpression of any opinion whatsoever on the part of the World Health Organization or the

International Labour Organisation concerning the legal status of any country, territory, city or area

or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on

maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they

are endorsed or recommended by the World Health Organization or the International Labour

Organisation in preference to others of a similar nature that are not mentioned. Errors and

omissions excepted, the names of proprietary products are distinguished by initial capital letters.

The World Health Organization and the International Labour Organisation does not warrant that the

information contained in this publication is complete and correct and shall not be liable for any

damages incurred as a result of its use.

Printed in Switzerland. Layout by rsdesigns.com.

Nations for Mental Healthii


5/77

ContentsPreface vi

Chapter 1

Introduction

1.1 Scope of the problem 1

1.2 Mental health problems cause disability 1

1.3 Using the workplace to prevent mental health problems andprovide solutions for referral and rehabilitation 3

Chapter 2

The importance of work to an individual’s mental health2.1 The workplace and mental well-being 5

2.2 Categories of psychological experience 5

Chapter 3

The workplace and mental health

3.1 Promotion of mental health in the workplace 6

Good Practice: Workplace activities for mental health – United Kingdom 7

3.2 Job stress – the stressful characteristics of work 63.3 Consequences of mental health problems in the workplace 8

3.4 Mental health and unemployment 9

Chapter 4

Mental health – an imperative concern

4.1 Issues facing employers and managers 11

Good Practice: Promotion/prevention – a case study on organizational stress 12

4.2 Country examples 134.2.1 United Kingdom – the health of the nation 14

4.2.2 Mental health issues in Finnish workplaces 14

Good Practice: Total wellness programme, Finland 15

4.2.3 Targeted intervention to facilitate return to work in Canada 14

Good Practice: The use of group process to facilitate work reintegration 16

4.3 Action needed 15

4.3.1 Specific steps an employer can take to help an employeereturn to work after treatment for a mental healthproblem such as depression 15

4.3.2 Employee assistance programmes (EAPs) 16

4.3.3 Practical suggestions for small businesses 17

Good Practice: Employee Assistance Programme, USA 18

Mental health and work: Impact, issues and good practices iii


6/77

Chapter 5

Work as a mechanism for reintegrating persons with serious mental illness

5.1 Size and profile of this group 19

5.2 Historical perspective 19

5.2.1 Deinstitutionalization 195.2.2 Organization of services 21

5.2.3 Psychosocial rehabilitation 21

5.2.4 Developing work skills 22

5.3 Current context: changes in the nature of work 23

5.4 Overcoming obstacles affecting clients’ ability to access work 24

5.4.1 Context 25

5.4.2 Overcoming obstacles linked to the illness 25

5.4.3 Overcoming obstacles linked to lack ofeducational training and lack of work experience 26

Good Practice: Supported education in Boston – Choose/Get/Keep 27

5.4.4 Overcoming obstacles linked to prejudice and stigma 28

5.4.5 Myths about mental illness and the workplace 29

5.4.6 Overcoming obstacles linked to government policy 30

5.4.7 Overcoming obstacles linked to the labour market 31

5.5 The perspective of international agencies 32

5.5.1 United Nations 32

5.5.2 World Bank and the Harvard Report 33

5.5.3 International Labour Organisation 34

5.5.4 World Health Organization 36

5.5.5 Nongovernmental organizations 37

5.5.6 Overseeing training and employment of persons with disabilities 37

Good Practice:Vocational rehabilitation for individuals with a psychiatric disability – 38

the Australia experience5.6 Rights of persons with serious mental health problems with

respect to access to work 39

5.7 International variations pertaining to culture, social structure andeconomics that may exist in developing countries 39

5.7.1 Countries in transition 39

Good Practice:A cotton factory in Beijing, China 40

5.8 Promoting the employment of persons with mental health problems 41

5.8.1 Political will and legislation 41

Good Practice: Towards “reasonable accommodation” of persons with mental health problems 42

5.8.2 Quota system 43

5.8.3 Support 43

5.8.4 Coordinated action 43

Nations for Mental Healthiv


7/77

5.9 Research findings 44

5.9.1 Potential predictors of successful participation 44

5.9.2 Developing work skills 44

5.9.3 Costs 47

5.9.4 Useful research tools 475.10 Successful work programmes at the international level 48

5.10.1 Utilization of supported employment programmes 48

5.10.2 Finding a job on the regular market 48

5.10.3 Developing social firms 49

5.10.4 Utilizing the cooperative movement 51

5.10.5 Other international examples 52

Good Practice: An American Bank 52

Good Practice: Service Cooperative, Italy 53

Good Practice: A complete furniture factory, Spain 53

Good Practice: Gardening project in Milan, Italy 54

Good Practice: An Olympic task, Montreal, Canada 54

Good Practice: A Mental Health NGO in Northern Ireland 55

Chapter 6

Discussion 56

Chapter 7

Conclusion 60

References 61

Mental health and work: Impact, issues and good practices v


8/77

Preface

All of us have the right to decent and productive work in conditions of freedom,equity, security and human dignity. For persons with mental health problems,achieving this right is particularly challenging. The importance of work in enhanc-ing the economic and social integration of people with mental health problems ishighlighted in this monograph.

The International Labour Organisation (ILO) has long recognized the impor-tance of documenting the extent of disabilities among the labour force and settingup effective preventive and rehabilitative programmes. The ILO’s activities pro-

mote the inclusion of individuals with disabilities in mainstream training andemployment structures. The importance of addressing specific issues related to theemployment of persons with mental health problems has also been recognized.

ILO promotes increased investment in human resource development, particularly the human resource needs of vulnerable groups, including persons with mentalhealth problems. Employees’ mental health problems and their impact on anenterprise’s productivity and disability/medical costs are critical human resourceissues. Increasingly, employers’ organizations, trade unions and government poli-cy-makers are realizing that the social and economic costs of mental health prob-lems in the workplace cannot be ignored.

Because of the extent and pervasiveness of mental health problems, the WorldHealth Organization (WHO) recognizes mental health as a top priority.

Using instruments that allow us to see not how people die but rather how they live (1), we now know that the problems of mental illness loom large around the

world. It accounts for 12% of all disability-adjusted life-years (DALYs), and 23%in high-income countries.

Five of the 10 leading causes of disability worldwide are mental problems (majordepression, schizophrenia, bipolar disorders, alcohol use and obsessive-compul-sive disorders). These disorders – together with anxiety, depression and stress –have a definitive impact on any working population and should be addressed

within that context. They may also develop into long-term disorders with accom-panying forms of disability.

Given the fact that numerous affordable interventions exist, the time has come to

challenge both the low priority given to mental health and the stigma that those with mental ill-health still endure around the world.

We now know that when essential drugs, if needed, are made available and accessis offered to a psychosocial rehabilitation programme (including the access tomeaningful and realistic employment) many persons will be able to lead moresocially and personally satisfying lives.

Nations for Mental Healthvi


9/77

WHO has made a renewed commitment to mental health in making it one of itspriorities. Mental health will be the theme of World Health Day 2001 and alsothe World Health Report 2001. Given the multifaceted nature of the factors thatcontribute to good mental health, WHO is ever mindful of the need to highlight

activities that foster good practices in mental health. In this monograph the issueof work as it relates to mental health is addressed.

The publication of this document is particularly important because it has broughttogether two large United Nations agencies involved in rehabilitation, namely

WHO and ILO. The document examines the importance of mental health in the workplace in general, and suggests appropriate management for workers withmental health problems. In addition, it takes a practical look at strategies to pro-mote and sustain good mental health while highlighting examples of good prac-tices.

The document was written jointly by Dr Gaston Harnois on behalf of WHO andPhyllis Gabriel on behalf of ILO. Dr Harnois is Director of the Montreal WHOCollaborating Centre at the Douglas Hospital in Montreal, Canada. He is also

Associate Professor of Psychiatry at McGill University, and former President of the World Association for Psychosocial Rehabilitation. Phyllis Gabriel MPH, MA is aVocational Rehabilitation Specialist at the ILO headquarters in Geneva. Shehas worked as a Vocational Rehabilitation Counsellor in US community-basedsocial service agencies as well as in mental health care facilities.

It is hoped that this important document will assist employers and employees inraising awareness of the benefits of good mental health practices and encouragethe implementation of strategies to maintain a healthy working environment.

Dr Benedetto Saraceno Mr Pekka Aro

Director Director

Department of Mental Health and InFocus Programme on

Substance Dependence (MSD) Knowledge, Skills and Employability

World Health Organization International Labour Organization

Mental health and work: Impact, issues and good practices vii


10/77

Nations for Mental Healthviii


11/77

Chapter 1

Introduction

1.1.Scope of the problem

There is growing evidence of the global impact of mental illness. Mental healthproblems are among the most important contributors to the burden of disease anddisability worldwide. Five of the 10 leading causes of disability worldwide are men-tal health problems. They are as relevant in low-income countries as they are inrich ones, cutting across age, gender and social strata. Furthermore, all predictionsindicate that the future will see a dramatic increase in mental health problems (2 ).

The burden of mental health disorders on health and productivity has long beenunderestimated. The United Kingdom Department of Health and theConfederation of British Industry have estimated that 15-30% of workers willexperience some form of mental health problem during their working lives. Infact, mental health problems are a leading cause of illness and disability (3 ). TheEuropean Mental Health Agenda of the European Union (EU) has recognizedthe prevalence and impact of mental health disorders in the workplace in EUcountries. It has been estimated that 20% of the adult working population hassome type of mental health problem at any given time (4 ). In the USA, it is esti-mated that more than 40 million people have some type of mental health disor-der and, of that number, 4-5 million adults are considered seriously mentally ill(5 ). Depressive disorders, for example, represent one of the most common healthproblems of adults in the United States workforce.

The impact of mental health problems in the workplace has serious consequencesnot only for the individual but also for the productivity of the enterprise.Employee performance, rates of illness, absenteeism, accidents and staff turnoverare all affected by employees’ mental health status. In the United Kingdom, for

example, 80 million days are lost every year due to mental illnesses, costingemployers £1-2 billion each year (6 ). In the United States, estimates for nationalspending on depression alone are US$ 30-40 billion, with an estimated 200 mil-lion days lost from work each year (7 , 8 ).

1.2 Mental health problems cause disability

As illustrated in this monograph, mental health problems affect functional and working capacity in numerous ways. Depending on the age of onset of a mentalhealth disorder, an individual’s working capacity may be significantly reduced.Mental disorders are usually one of the three leading causes of disability, together

with cardiovascular disease and musculo-skeletal disorders. In the EU, for exam-ple, mental health disorders are a major reason for granting disability pensions (9 ).

Disability not only affects individuals but also impacts on the entire community.The cost to society of excluding people with disabilities from taking an active part

Mental health and work: Impact, issues and good practices 1


12/77

in community life is high. This exclusion often leads to diminished productivity and losses in human potential. The United Nations estimates that 25% of the

world’s population is adversely affected in one way or another as a result of dis-abilities. The cost of disability has three components (10 ):

• the direct cost of welfare services and treatment, including the costs of disabili-ty benefits, travel and access, possible medication, etc;

• the indirect cost to those who are not directly affected (carers);

• the opportunity costs of income foregone as a result of incapacity.

For example, analysis of Tanzanian survey data has revealed that households with a

member who has a disability have a mean consumption less than 60% of that of theaverage household. This leads the authors to conclude that disability is a hiddenaspect of African poverty (11).

People with disabilities, particularly psychiatric disabilities, face numerous barriersin obtaining equal opportunities – environmental, access, legal, institutional and

2

Costs of occupational and work-related diseases

Source : Takala J. (ILO) Indicators of death, disability and disease at work. African Newsletter onOccupational Health and Safety, December 1999, 9(3):60-65.

7%

Mental disorders

9%

Respiratory disorders

8%

CNS

3%Tumours

3%

Skin diseases

40%

Musculoskeletal

16%

Heart disease

14%

Accidents

Nations for Mental Health


13/77

attitudinal barriers which cause social exclusion (12 ). For people with mental ill-ness, social exclusion is often the hardest barrier to overcome and is usually associ-ated with feelings of shame, fear and rejection.

It is clear that mental illness imposes a heavy burden in terms of human suffering,social exclusion, stigmatization of the mentally ill and their families and economiccosts. Unfortunately, the burden is likely to grow over time as a result of ageingof the global population and stresses resulting from social problems and unrest,including violence, conflict and natural disasters (13 ).

1.3 Using the workplace to prevent mental health problems and providesolutions for referral and rehabilitation

Globalization and interdependence have opened new opportunities for the growth

of the world economy and development. While globalization has been a powerfuland dynamic force for growth, work conditions and the labour market havechanged dramatically during the last two decades. The key elements in thesechanges are increased automation and the rapid implementation of informationtechnology. Workers worldwide confront as never before an array of new organiza-tional structures and processes – downsizing, contingent employment andincreased workload.

Employers have tended to take the view that work and/or the workplace are not

etiological factors in mental health problems. However, whatever the causal fac-tors, the prevalence of mental health problems in employees makes mental healtha pressing issue in its own right (14 ). Although, effective mental health servicesare multidimensional, the workplace is an appropriate environment in which toeducate individuals about, and raise their awareness of, mental health problems.For example, the workplace can promote good mental health practices and pro-

3

Source : United Kingdom Department for International Development. Disability, Poverty andDevelopment, February 2000 (modified)

DISABILITYPsychiatric

Social and culturalexclusion and stigma

Vulnerabilityto povertyand ill-health

Reduced participation indecision-making, and denialof civil and political rights

Deficits in economic,social and cultural rights

Poverty

Denial of opportunitiesfor economic, social andhuman development

Mental health and work: Impact, issues and good practices


14/77

vide tools for recognition and early identification of mental health problems, andcan establish links with local mental health services for referral, treatment andrehabilitation. Ultimately, these efforts will benefit all by reducing the social andeconomic costs to society of mental health problems.

For people with mental health problems, finding work in the open labour marketor returning to work and retaining a job after treatment is often a challenge.Stigma surrounds those with mental illness and the recovery process is often mis-understood.

This monograph addresses these issues. It provides a practical guide and resourcefor human resource managers, mental health professionals, rehabilitation work-ers, policy-makers, trade unionists and other concerned individuals.

The central themes of this monograph are:

• To examine the importance of mental health problems in the workplace.

• To consider the role of the workplace in promoting good mental health prac-tices for employees.

• To examine the importance of work for persons with mental health problems.

• To discuss the different vocational strategies and programmes for persons withmental health problems.

• To provide examples of good practices. These examples illustrate:

• good mental health promotional practices in the workplace by employers;• how to handle an employee who becomes ill with a mental health problem,

such as depression;• vocational rehabilitation models/programmes for persons with long-term

mental health problems.

4 Nations for Mental Health


15/77

Chapter 2

The importance of work to an

individual’s mental health

2.1 The workplace and mental well-being

The workplace is one of the key envi-ronments that affect our mental well-being and health. There is anacknowledgement and growing aware-

ness of the role of work in promoting orhindering mental wellness and its corol-lary – mental illness. Although it is diffi-cult to quantify the impact of work alone on personal identity, self-esteemand social recognition, most mentalhealth professionals agree that the workplace environment can have a significantimpact on an individual’s mental well-being.

2.2 Categories of psychological experience (16)Employment provides five categories of psychological experience that promotemental well-being:

• time structure (an absence of time structure can be a major psychological burden);

• social contact;

• collective effort and purpose (employment offers a social context outside the family);

• social identity (employment is an important element in defining oneself);

• regular activity (organizing one’s daily life).

Many large companies now realize that their employees’ productivity is connect-ed to their health and well-being. However, more emphasis has traditionally beenplaced on physical health than on mental health and well-being.

Several factors at a workplace can promote employees’ psychosocial well-beingand mental health. Especially important in this respect is the opportunity to beincluded in planning and carrying out activities and events in the workplace (e.g.

the opportunity to decide and act in one’s chosen way and the potential to pre-dict the consequences of one’s action). A related feature is the degree to whichthe environment encourages or inhibits the utilization or development of skills.Physical security, opportunity for interpersonal contact, and equitable pay arealso important.


Work is at the very core of

contemporary life for most people,

providing financial security, personal

identity, and an opportunity to make ameaningful contribution to

community life.

Source:NAMI (15).


16/77

Chapter 3

The workplace and mental health

3.1 Promotion of mental health in the workplace

Notions of mental health at work tendto focus on the individual rather thanthe organization. A comprehensive poli-cy of mental health at work includes,however, an assessment of the mentalhealth of the organization itself. The

gain to both individuals and the organi-zation from promoting good mentalhealth at work is reflected in increasedpresence, well-being and production.

The constant and unremitting rate of change that affects all businesses today is increasingly motivating employers toaddress the health of their staff. Moreover, it is taking its toll on employees, someof whom fail to cope with the changes and need support to help them avoidunder-performance and absenteeism. The global marketplace is forcing organiza-tions to upgrade their efficiency and this, in turn, is encouraging employers toseek ways of enhancing the performance of employees and to avoid losses associ-ated with health and safety (see example of Marks & Spencer, UK on page 7).

3.2 Job stress – stressful characteristics of work

Job stress can be defined as the harmfulphysical and emotional response that

occurs when the requirements of the jobdo not match the capabilities, resourcesor needs of the worker (18 ). Job stresscan cause poor health and can increaserates of work-related injuries and acci-dents. Some potential causes of work-related stress are overwork, lack of clearinstructions, unrealistic deadlines, lack of decision-making, job insecurity, isolated

working conditions, surveillance, and inadequate child-care arrangements (19 ) (seeexamples on page 10). Although sexual harassment and discrimination are oftenexcluded from lists of traditional job stressors, they must be included in any compre-hensive analysis of the causes of workplace stress. Sexual harassment is a stressor for

women in the workplace; and discrimination is a stronger predictor of health out-comes, including mental ill-health, for ethnic minorities than traditional job stressors(20 ). Some of the many effects of stress include numerous physical ailments as well asmental health problems such as depression and increased rates of suicide (21).


“We at the CBI are convinced that the

mental health of a company’s

employees can have an important

impact on business performance in

the same way as do industrial

relations climate or inadequate

training. That is why the CBI

continues to add its voice to the

campaign to raise the profile of mental

health as a workplace issue.”

Howard Davies, Director General,Confederation of British Industry.

The nature of work is changing at

whirlwind speed. Perhaps now morethan ever before, job stress poses a

threat to the health of workers and, in

turn, to the health of organizations.

Source: National Institute forOccupational Safety and Health, 1998.


17/77


Good practice: Workplace activities for mental health, United KingdomA large international retailer with 696 stores in many parts of the world including NorthAmerica,Asia and Europe employs some 56,000 people. Over 52,000 of these are employedin stores. 83% of the workforce is female and 62% of these are part-time.

Their stated policy is to take the mental health of its workforce seriously: “We realize that

in ensuring the mental well-being of staff we benefit from an individual and company pointof view.”

Strategy for health promotion

The strategy for overall health promotion, which includes mental health, is based on thefollowing:

• health education to raise awareness of factors affecting health and well-being;• screening programmes to detect risk factors or early signs of disease;• action programmes to do something about them.

The role of the occupational health service

The occupational health service works closely with personnel and line management regard-ing all aspects of mental and physical health of employees. The occupational health team isavailable to look at the effects of health on work or of work on health, to discuss with staff

any health problems they may have and to promote good health through health education,screening and action programmes.The company believes that an occupational health serv-

ice can play a major role in helping:

• to identify work problems caused by mental ill-health;• to take action to improve the health of employees;

• to assist employers in modifying the work and work environment;• to enable employees to remain at work rather than withdraw.

The organization assists in preventing mental ill-health by giving people a good working

environment and a clearly defined job. Following absence, it is often essential to be able to

modify working hours during the rehabilitation period and to provide a gradual return tousual working practices through a good sick pay scheme. Financial support at this timeallays anxiety and encourages a speedier return to work.

Regular honest appraisals are important and problems in performance should be discussed

when they occur, with an opportunity to follow up and review progress. People should feelable to contribute to their development and feel accountable for their jobs.

On-site counselling facilities from personnel or health professionals are available, reducing

time away from work (17 ).


18/77

There is growing global concern about the impact of job stress, including issuesrelated to gender, ethnicity, sexual harassment, violence and mobbing at work,family, and underemployment (22 ). Job stress is one of the most common work-related health problems in EU countries. The Second European Survey on

Working Conditions indicated that 28% of workers reported that their work caus-es stress. In Japan, the proportion of workers who report serious anxieties orstress in relation to their working life increased from 53% in 1982 to 63% in1997. In developing countries, there is increasing concern regarding the healthimpact of job stress. For example, an increased risk of work-related illnesses andaccidents has been observed in South-east Asian countries that have experiencedrapid industrialization (23 ).

In most countries there is no specific legislation addressing the impact of jobstress. Most countries have at least minimum standards for safety and health fea-

tures of the workplace. These standards tend to focus on the physical aspects of the workplace and do not explicitly include the psychological and/or mentalhealth aspects of working conditions. Notable exceptions include theNetherlands and the Nordic countries (24).

3.3 Consequences of mental health problems in the workplace

The consequences of mental health problems in the workplace can be summarizedas follows (25 ):

Absenteeism

• increase in overall sickness absence, particularly frequent short periods of absence;

• poor health (depression, stress, burnout);

• physical conditions (high blood pressure, heart disease, ulcers, sleeping disor-ders, skin rashes, headache, neck- and backache, low resistance to infections).

Work performance

• reduction in productivity and output;

• increase in error rates;

• increased amount of accidents;

• poor decision-making;

• deterioration in planning and control of work.

Staff attitude and behaviour

• loss of motivation and commitment

• burnout



19/77


• staff working increasingly long hours but for diminishing returns

• poor timekeeping

• labour turnover (particularly expensive for companies at top levels of

management).Relationships at work

• tension and conflicts between colleagues;

• poor relationships with clients;

• increase in disciplinary problems.

Workers’ health is a separate goal in its own right. Addressing mental health

issues in the workplace means incorporating social responsibility in a firm’s every-day practices and routines.

3.4 Mental health and unemployment

Re-employment has been shown to beone of the most effective ways of pro-moting the mental health of the unem-ployed (26 ).

A review of studies of the mental andphysical health effects of unemploymentand the mechanisms by which unem-ployment causes adverse health out-comes reveals a complex relationship.There has been a serious debate aboutthe direction of causality. Does unem-ployment cause deterioration in health,both mental and physical? Are the sick

more likely to become unemployed?

In a study reported in the Journal of Community Psychology (28 ), an analysis of employed respondents revealed that those who became unemployed had overtwice the risk of increased depressive symptoms and diagnosis of clinical depres-sion than those who remained employed. Furthermore, the data did not supportany relationship between clinical depression and becoming unemployed. In therespondents’ community at the time of the study, depression was not a causal fac-tor for the unemployment rate. The incidence and prevalence of depression

increased once individuals became unemployed.

Fact: The National Institute of Mental

Health estimates that more than 3

million adults aged 18-69 have a

serious mental illness. Estimates of unemployment among this group are

70-90%, a rate higher than for any

other group of people with disabilities

in the USA. Recent surveys report that

approximately 70% of those with

psychiatric problems rank

employment as an important goal.

Source:NAMI (27).


20/77


Stressful characteristics of work

Condition defining hazard

Work characteristics (demands,control and support)

CONTEXTOrganizational function and culture Poor task environment and lack of

definition of objective

Poor problem solving environment

Poor development environment

Poor communication

Non-supportive culture

Role in organization Role ambiguity

Role conflict

High responsibility for people

Career development Career uncertainty

Career stagnation

Poor status or status incongruity

Poor pay

Job insecurity and redundancy

Low social value to work

Decision latitude/control Low participation in decision-making

Lack of control over work

Little decision-making in work

Interpersonal relationships at work Social or physical isolationPoor relationships with supervisors

Interpersonal conflict and violence

Lack of social or practical support at home

Dual career problems

CONTENT

Task design Ill-defined work

High uncertainty in work

Lack of variety of short work cycles

Fragmented or meaningless workUnderutilization of skill

Continual exposure of client/customer groups

Workload/work pace Lack of control over pacing

Quantities and quality Work overload or underload

High levels of pacing or time pressure

Work schedule Shift working

Inflexible work schedule

Unpredictable working hours

Long or unsociable working hours

Consensus from literature outlining nine different characteristics of jobs, work environment

and organization which are hazardous.

Source : HSE Contract Research Report No. 61/1993. Cox T. Stress Research and Stress Management: Putting Theory to Work .


21/77

Chapter 4

Mental health:

an imperative concern4.1 Issues facing employers and managers

Although our knowledge of mental health issues has increased over the past few decades, employers and enterprises have lagged behind in their understandingand acceptance of the pervasiveness, treatment and impact of mental health prob-lems on organizational life (29 ). Most human resource management and publicadministration training programmes do not cover adequately the area of mentalhealth and employment. Recognition of mental illness in the workplace is oftendifficult for there is often a psychological component to physical symptoms andphysical ailments may be present in some mental disorders (30 ). Whatever theoriginal cause, employers and managers are faced with three main issues as they attempt to address the mental health needs of their employees:

Recognition and acceptance of mental health as a

legitimate concern of organizations (31)

There is a need among employers to recognize mental health issues as a legiti-

mate workplace concern. As disability costs and absenteeism increase in the work-place due to mental ill-health (whatever the precipitating factors), more andmore employers are faced with the challenge of developing policies and guide-lines to address these issues.

Effective implementation of a country’s anti-discrimination provisions (32)

The last decade has seen a significant increase in anti-discrimination legislation spe-cific to employment for people with disabilities. Although many of these laws andstatutes have weak enforcement mechanisms, there is an increasing need foremployers and their human resource managers to understand how these laws affecttheir company’s employment policies.

Preventive, treatment,and rehabilitation programmes that

address employees mental health needs

The development of appropriate prevention and mental health promotion policiesin the workplace is an increasing concern for many employers. Understanding theneed for early intervention and treatment, as well as reintegrating an employee

into the work environment, is also a critical challenge.



22/77

Good practice: Promotion/prevention –a case study in organizational stress, United Kingdom

A Mental Health Trust – organizational stress pilot for employees (33)A Mental Health Trust employs some 846 people and provides mental health services to alarge catchment area in Britain.The trust’s data showed that stress-related illness was

responsible for 25% of all absence.To address this issue, the trust implemented the HealthEducation Authority’s anti-stress pilot programme designed to reduce the anxiety and ten-

sion of employees within the organization.The programme was introduced at a time of major organizational change at the trust.As a result of the programme, absenteeism due to

stress-related conditions was reduced. Moreover, a “general sense” of improved moraleamong the employees was noted.

Key components

• Formation of a Stress Management Group (SMG).The SMG managed the programme. Itwas usually led by the human resource director with the full support of the chief executive.

• The Listening Group.This was a two-day event for 25-30 people representing all sections

of the organization. The Listening Group was led by the consultants to the programme.Its aim was to develop a preliminary analysis of the nature and extent of organizational

stress by listening to the views of the staff.

• Post -Listening Group action. Following the Listening Group, the SMG worked with con-sultants to plan the Organizational Stress Workshop on the basis of the findings of the

Listening Group.

• The Organizational Stress Workshop. This was a second two-day event for 30-60 peoplewho had a particular involvement in the findings of the Listening Group.Their role was

to draw up action plans.

• The Action Groups. A number of groups were formed, coordinated by the SMG, to see

through the action plans over a period of months or even years.

Reasons for stress as expressed by the employees in the Listening Group

• Staff felt uninvolved in the planning and process of change, leading to a loss of control,

of choice and ownership and a sense of devaluation and powerlessness.

• Staff did not know what was happening when it happened. Decisions could change

from one week to the next.

• Many were struggling to cope with changes in their work environment, such as servicerelocations and new methods of recording information.



23/77

Outcomes/effectiveness

Sickness absence in the Mental Health Trust

1993-4 1994-5 1995-6 1996-7 1997-8

6.17% 5.72% 5.59% 5.6% 4.79%

Proportion of sickness absence due to stress, 1993-1997

1993-4 1994-5 1995-6 1996-7 1997-8

19.9% 20.4% 20.2% 19% 16.8%

Employees’ comments after participation

Managers were generally more enthusiastic about the programme than staff. Most partici-

pants in workshops or action groups felt they had benefited. Several described the pro-

gramme as “therapeutic” and constructive.

Communications were better, more information was getting through, the lead up to the

move was better. It felt as though there was more support and team effort. “Things arechanging in my department - there’s more on offer, training, support but don’t know if it’s

the result of this intervention.”

A few identified other beneficial changes in attitudes or culture.Before the project it had notbeen possible to admit to certain feelings, such as being upset about the closure,but now it was.

Some felt more confident that things could be influenced from the bottom up.


4.2Country examples

4.2.1 United Kingdom – The health of the nation (34)

The Health of the Nation is a national response to WHO’s campaign for Health

for all by the year 2000 . It sets goals for health outcomes and selects mental ill-nesses as a priority area.

The overall mental illness goals are to prevent mental illness, improve health andsocial functioning of people with mental illness, reduce mortality from mental ill-ness, reduce stigma, deliver effective services, and continue research into causes,care and consequences of mental illness.

The national targets for mental illness are:

• to significantly improve the health and social functioning of mentally ill people;• to reduce the overall suicide rate by at least 15% by the year 2000 from the

1990 level of 11 per 100,000;

• to reduce the lifetime suicide rate of severely mentally ill people by at least 33%by the year 2000.


24/77

The overall strategy to achieve the targets is:

• to improve information and understanding about mental illness;

• to continue developing local comprehensive services;

• to promote good practice in mental health promotion, primary, secondary andtertiary prevention, and prevention of mortality.

The mental illness key area encompasses the National Health Service (NHS) as wellas a whole range of organizations and settings such as local authorities, the volun-tary sector, the criminal justice system, schools, workplaces, cities and rural areas.

Since the United Kingdom does not have a national occupational health service,many large employers have established their own occupational health services fortheir employees.

4.2.2 Mental health issues in the Finnish workplace (35)

Measures most commonly taken at the Finnish workplace aim to:

• improve work environment (e.g. enhancing occupational safety and ergonom-ics, communication, clear goals, independence at work);

• provide further training and learning opportunities (e.g. improving occupation-

al skills and team work or promoting independent studying);• promote health (e.g. promoting physical activities, healthy lifestyle, offering

rehabilitation and preventing substance abuse).

The Finnish Institute of Occupational Health recommends the following meansto promote mental health in work organizations (36 ):

• to implement models of good workplace practices and disseminate this informa-tion in the community;

• to increase the cooperation of mental health and occupational health profes-sionals in promoting mental health activities at the workplace;

• to train occupational health care professionals in mental health issues and men-tal health professionals in work-life issues.

• to increase the general knowledge of the whole population regarding the pre-conditions for and value of good mental health in working life, and develop self-help skills for creating satisfactory working conditions.

4.2.3 Targeted intervention to facilitate return to work

The Association of Canadian insurance companies estimates that 30-50% of dis-ability allowances are paid on account of mental health problems. This is thereforethe principal cause of long-term absences from one’s job. The experience of many employers is that once an employee is absent for “mental health” reasons for 3months, the likelihood is very high that the absence will last more than 1 year.



25/77


4.3Action needed

4.3.1 Specific steps an employer can take to help an employee return to

work after treatment for a mental health problem such as depression (37)

• Inform the attending physician or appropriate mental health professional of the exact duties of the job before the physician makes a final decision on returnto work.

• In consultation with the individual’s physician or other mental health profes-sional, encourage an early to return to work. The longer an employee is out of

work due to treatment, the more he/she will worry about losing the job.Furthermore, the longer a person is away from the job, the more mentally detached he or she will become.

• Consider gradual return to work. Allowing part-time work for several weeksmay help reduce stress, leave time for additional medical counselling and allow the worker to quickly get back into a normal routine. Flexitime, temporarily changed duties that involve less job-related stress or other flexible arrangementsmay be useful. However, there should be a clear understanding between theemployee and the employer as to the details of the return-to-work programme:the expected length of time for which special accommodations will be granted,

what day-to-day flexibility is allowed, the exact duties of the employee and who will supervise the work.

Good practice: Total Wellness Programme,Finland

One of the world’s leading wireless and wireline telecommunications firms runs a total well-

ness programme which includes mental health issues for its employees.The programme’s pur-pose is to create an efficient and healthy workplace and health promoting working conditions.

This company’s human resources and occupational medicine departments are responsible forworkplace health promotion and prevention programmes.The Total Wellness Programme was

developed in collaboration with the Finnish Institute of Occupational Health.

To plan its health promotion activities, the company uses its own statistics on working dayslost due to illness, industrial accidents and occupational diseases, as well as data on staff satis-

faction and the health of employees.The occupational medicine department organizes medicalexaminations and assessments of the need for rehabilitation.As part of the fitness survey,

employees are assessed on a scale of one to five on health-related issues such as work, physi-cal condition, and ability to cope with stress, family life, social contacts and hobbies. Receiving

the lowest score in any of these sections prompts quick intervention to determine how the situ-ation can be improved. Participation in the programme is evaluated on a regular basis.Work

stressors and health and career development are part of the agenda of annual developmentdiscussions between employees and their superiors.The company places great emphasis oncontinuing professional education. It has established its own global learning centre network.


26/77

• Other possible stress-reducing accommodations include:

• altering the pace of work;• lowering the noise level of work;• providing water, tea or soda and crushed ice to combat a dry mouth caused

by some medications;• extra encouragement and praise of job performance, but only if warranted

and not obviously excessive;• while taking steps to reduce stress, avoidance of over-protection of the

employee;• making sure the employee is treated as a member of the team and not exclud-

ed from social events, business meetings or other activities relevant to the job.

4.3.2 Employee assistance programmes

Employee assistance programmes (EAPs) are company-sponsored programmesdesigned to alleviate and assist in eliminating workplace problems caused by per-


Good practice: the use of group process to facilitate workreintegration of employees with mental health problems in CanadaA 12-week programme was created to bring about a “synergetic partnership” and adynamic alliance between employee, employer, health professionals, unions and insurance

companies.

The programme, offered to no more than 12 individuals at any one time, combines groupintervention and an individual action plan; it is action-oriented and centred on the regain-

ing of power for the person.

First, the programme aims at:

• identifying and resolving collective and individual problems;• reviewing vocational skills and interpersonal relationships;

• consolidating job skills.

Secondly, the employee is accompanied in the negotiation of his/her progressive return towork.A joint supervisory process (involving the employee, the vocational consultant and

the employer) takes place on the job scene.This serves to give confidence to the employeewhile at the same “sensitizing” other workers.

Thirdly, in order to avoid relapses and to consolidate job stability, the individual is followed

up for 6 months and as needed thereafter.

Results: After 2 years, 85% of the employees who took the programme have returned totheir jobs and are still in them.

Cost : The programme costs Cdn.$ 2600 (US$ 1700) for 12 weeks.

Charbonneau, C.: Accès Cible S.M.T. Dix ans à faire renaître la confiance. November 1998.


27/77

sonal problems. These programmes typically provide supportive, diagnostic,referral and counselling treatment services. Many EAPs began as occupationalalcoholism programmes and gradually evolved into broader-based efforts asemployers recognized that alcoholism was not the only problem that could nega-

tively affect job performance. Although some EAPs continue to focus only on identifying and assisting workers who are substance abusers, most now offer a wide range of other services to helpemployees resolve personal and work-related problems. These services may include:

• on-site and telephone counselling;

• referral for psychological symptoms or mental health disorders (e.g. depres-sion, stress, anxiety);

• marital or family-related issues;

• legal and financial problems;

• catastrophic medical problems (e.g. AIDS, cancer);

• pre-retirement planning needs;

• career-related difficulties (38 ).

Many EAPs have been affected by changes in national and regional legislation. Asan employer develops programmes to respond to national policies as well as legis-lation, EAP professionals have had to become knowledgeable about the statutesand how they affect their company’s employees and policies (39 ).

4.3.3 Practical suggestions for small businesses (40)

Often the smaller employer (with fewer than 25 employees) cannot afford tohave a specific EAP or medical and rehabilitation experts on the staff. However,the model that is often used by many large employers can be adapted to a small

setting:

• The personnel or human resource director or other appropriate officer of thecompany should visit the employee who is on a medical/disability leave as soonas possible to demonstrate concern and to encourage an early return to work.

• Always try to return the worker to his or her old job, even if an accommodationor flexible work time is required. This minimizes complications to the employ-ee, reduces stress which may trigger a reoccurrence of depressive symptoms, andmaximizes the company’s advantage of having a trained employee.

• Use community resources. Local rehabilitation agencies and support groups may aid in a successful return to work with minimal or no expense to the business.

• Make a special effort to inform the employee’s physician or mental health pro-fessional regarding the requirements of the job and possible changes andaccommodations.



28/77

Good practice: Employee assistance programme,USA

A large diversified health care company with more than 54,000 employees.

The following psychiatric disability case illustrates the benefits of an effective workplaceprogramme to manage mental health problems.An office assistant in her early thirties was

a divorced single mother with two children. Her manager, having observed her recent prob-lems with concentration and productivity, referred her to the company’s EAP.

Due to the severity of the employee’s condition, the EAP recommended that she be placed

on medical leave. The employee, who had a history of childhood abuse and symptoms of depression, had been under the care of a psychiatrist and therapist.These providers were

not responsive to the EAP’s request for additional evaluation and more intensive outpatient

treatment.Therefore, with the employee’s agreement, she was referred to in-networkproviders, a psychiatrist and psychologist team, who quickly determined that she neededmore timely intensive care. Her medications were modified and she began partial hospital-

ization treatment.The EAP case manager also arranged for the employee to receive finan-cial assistance through a company programme, which helped to reduce her level of stress.

After seven weeks, the woman had stabilized and was returned to work. However, shortly

thereafter she had a relationship break-up and quickly slipped back into crisis mode, includ-ing suicide ideation.The employee was again placed on medical leave and her providersadmitted her to an inpatient programme. After a few days in the hospital, the employee

stabilized again, returned to partial hospitalization and began attending a depression sup-port group.

Within six weeks, the employee returned to work for a second time. This time, she was

eased back into the work routine, beginning on a part-time basis and slowly increasing herwork hours. Within a month, she returned to full-time work.The EAP case manager main-

tained contact with her after the return to work, and also worked with the employee’s man-ager to ensure a successful transition back to work. The employee has since demonstrated

positive progress with a good prognosis.

Over a 10-month period, the EAP had made a total of 163 contacts with the employee,providers and company personnel.This investment in support has enabled an employee

who had been a probable candidate for long-term disability to remain productive (41).



29/77

Chapter 5

Work as a mechanism for

reintegrating persons withserious mental illness

5.1 Size and profile of this group

According to WHO, more than 500million people around the world are

afflicted with serious mental illness,alcoholism and/or drug addiction.Expressed differently, 1.5-2% of thepopulation of each country has to facethis issue.

According to ILO (43 ), mental illnesshits more human lives and gives rise to agreater waste of human resources thanall other forms of disability.

The unemployment rate of this group is around 90% — in contrast to that of per-sons with physical or sensorial disabilities, which is approximately 50%. Again,expressed differently, only 10% of persons with a serious psychiatric background

who wish to work and are judged capable of working are in fact working. Womenfare less well than men.

It has long been known that severe mental illness often impairs dramatically one’scapacity to work and to earn a living. It can lead to impoverishment, which in

turn may worsen the illness. Thus, all efforts to find employment for these per-sons are essential since they improve quality of life and reduce both impoverish-ment and the high service and welfare costs engendered by this group (44 ).

5.2Historical perspective

Tremendous changes have taken place in the management of persons with severemental illness over the past 50 years.

5.2.1 DeinstitutionalizationUntil the early 1950s we had to resort to long-term hospitalization, usually in apsychiatric hospital, since few very effective treatments were available. The nega-tive side of prolonged hospitalization was that patients not only had the signs andsymptoms of their illness but also had a tendency to lose the social skills whichthey possessed that are required in order to live in society (such as the ability to


“We have been asking for the means to

actively construct the real access to

rights for years: not only the right to

medical care, but also the right to

produce,to have a house,an activity, a

relationship, economic means, value.”

Source: Franco Rotelli (42)


30/77

dress and to feed oneself appropriately, to relate to other persons, to take the bus,

or go to the bank, etc.). This phenomenon, referred to as “institutionalization”,became more evident when the first neuroleptic drugs (“tranquillizers”) were dis-covered in the 1950s. These had the capacity to control symptoms such asthought disorder, hallucinations, restlessness and agitation. Their discovery had adramatic impact on the life of many long-term psychiatric patients who couldthen be discharged much more rapidly and also benefit from other treatmentssuch as psychotherapy. However, a good number of patients whose active symp-toms were well looked after with the first and successive generations of neurolep-tic medication were still showing other symptoms such as withdrawal, lack of

motivation, a certain degree of apathy, and the so-called “negative symptoms” of major psychiatric illness, most notably schizophrenia. It is only since 1985 that we have medications available (so-called atypical neuroleptics) that can signifi-cantly impact on negative symptoms.

20

Disabled people with mental health problems and work,United Kingdom

(Total of working age with mental health problems = 475,000)

Source : Labour Force Survey, Spring 1998. United Kingdom Educational and EmploymentCommittee, Opportunities for Disabled People

In employment 12%

“Looking for work” 4%

57 000

20 000

398 000

Economicallyactive

Economicallyinactive

“Not actively looking for work” 84%

Nations for Mental Health


31/77

All the above medications are powerful and they must always be carefully pre-scribed and monitored. Several can cause secondary effects such as thirst, invol-untary movements and problems with vision, although this is less frequent withthe newer molecules.

The other categories of illnesses normally included under the term “severe men-tal illness” are the major depressions, be they unipolar or bipolar (“manic-depres-sive illness”). Tricyclic antidepressants and MAO inhibitors are used for theformer and mood stabilizers (mostly lithium carbonate) for the latter.

5.2.2 Organization of services

In developed countries today, most admissions take place in general hospitalsrather than in psychiatric hospitals.

A substantial percentage of persons are able to return to live in society, either with their own families or in different types of living arrangements with more orless need for supervision and support. Many patients can be treated in day ornight hospital programmes. By far the majority of patients are treated as outpa-tients, ideally by a multidisciplinary team that participates in carrying out a planor project that has been developed jointly with the patient.

Today, the vast majority of persons with mental illness live in the community and

not in institutions.

5.2.3 Psychosocial rehabilitation

Coincidental with these changes, we have witnessed a rapid development in thefield and practice of psychosocial rehabilitation, a discipline which aims to over-come the difficulties of playing a social role and living in a social environment(45 ). The emphasis is on skills and abilities rather than on symptoms and disabili-ties, and the focus is on the areas of activities of daily living, socialization and

work. The practice of psychosocial rehabilitation can be done by existing profes-

sionals such as psychiatrists, psychologists, social workers, occupational therapistsand nurses if they have the necessary skills and training, or by persons who havereceived specific training in psychosocial rehabilitation in university programmes

which are growing more numerous nowadays. All groups share a belief that mostpersons with serious mental health problems can improve if properly evaluated,trained and supported in the community (46 ).

Whereas physicians (mostly psychiatrists) are responsible for hospital admissionsand treatment, including the prescription of appropriately monitored medication

(which a majority of patients will require, often for long periods of time), mostfacets of reintegration and life in the community are looked after by professionals who use a psychoeducational approach rather than a medical one.



32/77

With appropriate treatment and psychosocial rehabilitation programmes, many people who would formerly have had to spend years in psychiatric institutions arenow able to lead fairly interesting lives in the community.

Mental illness should be distinguished from mental retardation. The latter refers tosubnormal intellectual functioning which usually begins before adulthood (47 ).

5.2.4 Developing work skills

While our focus is on access to paid employment, we know that a majority of per-sons with severe mental health problems have been exposed to programmes thatfocus more on developing work skills than on actual paid work. These pro-grammes are summarized briefly (48 ).

• Hospital-based programmes of training and work integrationThese are less used now than in the past; their aim is to increase self-confidenceand general functioning and the type of activities that one finds in such pro-grammes include food distribution, gardening, running a small store, etc. Whileparticipants tend to have reduced numbers of days of hospitalization, it appearsthat few obtain successful permanent employment.

• Sheltered workshops

This is another traditional approach where subcontract work is used. It is felt thatthis type of work does not prepare very well for remunerative employment andthat the person tends to remain in a patient role. However, 10-15% of partici-pants have been found capable of moving to a more intensive programme.

• Training in community living

These programmes have been developed through the pioneering efforts of Stein,Test & Marx (49 ). They attend to basic needs and feature strong individual man-agement as well as a global approach. While participation in such programmes

reduces hospitalization and increases independent living, it has not been found tohave a great impact on keeping a permanent job.

• Programmes of assertive community treatment (PACT)

These programmes were also developed by Stein, Test & Marx in response to thegrowing need for community-based services for persons with severe mental ill-ness. The focus has been on recovery from illness and enhanced quality of life.This training has been implemented in Canada and in several areas of the UnitedStates. PACT is an interdisciplinary team approach including a psychiatrist, regis-

tered nurses, peer specialists, vocational specialists, an addiction specialist and aprogramme administrator. Crisis care is available 24 hours a day.

This integrated, community-based model provides “the treatment, rehabilitation,and support services that persons with severe mental illness need to live success-fully in the community” (50 ).



33/77

The clinical principles of treatment include, in part, an assertive approach tokeeping individuals involved; continuous monitoring to maintain current knowl-edge of their functioning and to facilitate intervention when necessary; and indi-

vidually tailored treatment and rehabilitation programmes (51).

PACT appears to be the model that has resulted in the most candidates beingable to obtain increased competitive employment.

Other approaches are described later under 5.10.

5.3Current context: changes in the nature of work

Obtaining competitively paid employment for a person with a background of serious mental illness remains a challenge at the best of times. It is even more dif-

ficult in periods of high unemployment when the availability of nondisabled workers is plentiful.

Globalization, technological development and changes in the organization of work are having an impact worldwide (52 ).

In the manufacturing sector of OECD countries, the employment of unskilledlabourers has fallen by 20% (53 ) and there is a definitive trend towards the hiringof highly-skilled workers.

We are forced to acknowledge that important changes have taken place in the very nature and organization of work: the free-market economy which predomi-nates, is often accompanied by downsizing of human resources and increased lossof job security. Moreover, various governments, in order to balance their budg-ets, have felt the need to reduce their social costs from which persons with seriousmental illness traditionally get support: conditions of eligibility have been madestricter and the duration of the support programme often shorter.

With respect to the near future, there seem to be two schools of thought – one

pessimistic and the other more optimistic.

The pessimist’s viewpoint, as represented by sociologist Jeremy Rifkin (54 ), statesthat we are nearing the “end of work”. The recent technological advances haveresulted in a sharp reduction of new jobs in the industrial sector and he predictsthat, with the assistance of computer technology, the reduction will be evengreater in the services sector.

The optimists, as represented by Charles Goldfinger, are of the opinion that

“each time a new technology is developed, it brings not a decrease, but anincrease in job opportunities, albeit, not necessarily of the same kind as before”.The new economy contains huge pools of new jobs which can more than makeup for the inevitable loss of traditional jobs” (55 ). This latter viewpoint seems tobe borne out in several countries that have experienced sustained growth in the



34/77

last few years: this has “revived the demand for a great variety of workers in many spheres of economic activity” (56 ).

Supporters of both viewpoints seem to agree that the organization of work is

becoming more intangible and that regular 8 to 5 jobs may be less common, tobe replaced by “flexible schedule, increased part-time work, short-time contracts,often done in the employee’s own home…”

There seems to be agreement that the newer jobs will be in the following sectors:

• handling information and knowledge;

• information technology;

• the health sector;

• the leisure economy.

Whenever they have been successful in finding a paid job in the past, persons with abackgound of serious mental illness tended to work either in the traditional indus-trial sector or in service areas that did not require high technological capacity.

While it is too early to predict what will happen in the 21st century, it is obviousthat work programmes for these persons will have to take into account thechanges in the nature of work. This will include the need for a better educationand the development of professional skills in keeping with the requirements of the new jobs.

5.4 Overcoming obstacles affecting clients’ability to access work (57)

Individuals with mental illness want to work but are often discouraged by many barriers in the current public system. A recent survey in the United States

showed that 72% of unemployed people with disabilities, including people withsevere mental illness have a strong desireto work. Several recent surveys havefound this rate to be as high as 80% foradults with mental illnesses (58 ).

Employment is an essential part of recovery for people with mental illness-es and recent advances in treatmentservices and medications have increased the capacity of people with mental ill-nesses to join the mainstream and live independently.


Six principal barriers to the

employment of individuals with severe

mental illness:

1. Lack of choice in employment

services and providers.

2. Inadequate work opportunities.

3. Complexity of the existing work

incentive systems.

4. Financial penalties of working.

5. Stigma and discrimination.

6. Loss of health benefits.


35/77

5.4.1 Context

Shorter periods of hospitalization when needed and appropriate follow-up in thecommunity prevent people from losing the social skills that are essential to ade-quate living in the community. The approach is also somewhat less costly to gov-ernments. However, we find that, while they are saving millions of dollars by closing psychiatric beds, at least in most developed countries, few governmentshave promulgated policies and developed community resources necessary toensure the social integration of these patients. It takes greater political will andskills to put in place the conditions and programmes that will permit the mean-ingful return to life and society (including work) of persons with serious mentalillness than it does to close a psychiatric hospital.

In the past, policies and programmes have tended to lump together the require-

ments of persons with mental retardation and those of persons with serious men-tal illness. Whereas they can have several needs in common, it has to be realizedthat the requirements for both groups are vastly different when it comes to “rea-sonable accommodation”.

It is useful to review how to overcome the main obstacles that impact on the abil-ity of persons with serious mental illness to have access to work.

5.4.2 Overcoming obstacles linked to the illness

A substantial majority of persons with serious mental illness take medication. When appropriately prescribed and monitored, these medications, especially thenewer molecules, not only control the positive symptoms of illness (agitation,restlessness, etc.), but also have a significant impact on negative symptoms suchas apathy, passivity and social withdrawal, as well as interpersonal relationships.

All in all, 60-80% of persons with serious mental illness can be substantially helped with a well monitored medication regime and an appropriate psychosocialmanagement and support programme.

It remains essential for persons with serious mental illness to have access to (andbe able to afford) both appropriate medication and a psychosocial programmethat will focus on the person’s living conditions, his/her ability to relate to oth-ers, and his/her willingness and capacity to work. In all instances the person’schoices must be sought and taken into account.

There is still a debate as to how much an employer should (or wants to) know concerning an employee’s psychiatric background. In all modern legislation, dis-ability cannot be sufficient grounds to refuse employment if otherwise the person

can do the job.The assurance that there will be a quick and easy access to appropriate medicaland psychological help has been found to influence very positively the willingnessof employers to offer jobs to persons with mental health problems.



36/77

In the past, and still today, many persons with psychiatric backgrounds have hadto lie to a potential employer about their illness. Some of the most successful pro-grammes are those where a mutual trusting and respectful attitude has beendeveloped so that issues that may arise are easier to address.

5.4.3 Overcoming obstacles linked to lack of educational training and

lack of work experience

Mental illness can strike at any age of life: some of the most severe forms begin inthe late teens and early twenties and usually prevent the person from completingsecondary education, college and/or university. This renders the person ill-equipped to face the requirements of a job, especially in today’s world. Otherforms of illnesses start in the late twenties and early thirties while the person isalready working.

The work milieu is often intolerant of a colleague suffering from mental illness;the first episode may result in a demotion or a change of job, if not an outrightfiring. The impact on the person’s self-esteem is usually very negative. The loss of one’s remuneration brings with it economic hardship, notwithstanding the vari-ous aid programmes that exist in developed countries.

Research has shown a constant positive relationship between the skills of a clientand his/her vocational outcome (59 ) and that persons with severe psychiatric dis-

ability can indeed learn new skills (60 ). With the ever-increasing importance of technology, we find that the “low-tech jobs” to which many persons with seriousmental illness had access in the past are no longer available, at least in developedcountries.

We need to develop training programmes that take into account the needs of per-sons with mental health problems as well as the requirements of potentialemployers.

In low-income countries, greater use should be made of the apprenticeship model.

We now believe that it makes eminent sense to encourage someone whose aca-demic career was interrupted by mental illness to go back to school, college or uni-

versity, in order to complete a qualification and therefore have access to a much wider choice of jobs and opportunities. Whereas government programmes havetraditionally supported direct employment, there now exists a number of supportprogrammes that will allow one to return to school.



37/77

Good practice: Supported education in Boston – Choose/Get/Keep

As part of its array of rehabilitation services, a University-based Centre for PsychiatricRehabilitation has developed an extensive programme of “supported education”. The cen-

tre applied a basic model (61) called “Choose/Get/Keep” which was initially developed forpersons seeking a return to employment.

Supported education has been defined (62 ) as “the provision of post-secondary education

in integrated educational settings for people with psychiatric disabilities whose educationhas been interrupted, intermittent or has not yet occurred because of a severe psychiatric

disability, and who, because of this psychiatric impairment, need ongoing support servicesin order to be successful in the educational environment.”The programme utilizes “sup-

ported learning specialists” with a masters degree in psychiatric rehabilitation (practition-

ers) who assist and accompany the person with a former psychiatric disability throughoutthe three phases of the programme. The guiding principle is to focus on “participantprocess” rather than on “practitioner activity.”

• In the “Choosing” phase the participant is helped in describing why he/she wishes to go

back to school and in making an enlightened choice as to the type of environmentwhich suits his/her needs, as well as in making a choice as to which school might meetexpectations. The eliciting of educational goals, the assessment of personal criteria, and

the realistic objective evaluation of the student’s abilities are paramount in facilitatingthe decision-making process. Part of this phase also involves the identification and

securing of other sources of support for the student, including family and friends.

• In the “Getting” phase a decision is made by the practitioner and the student concern-ing the assignment of responsibility for getting enrollment in the academic facility cho-

sen, including obtaining the financial support needed.A decision has to be madeconcerning the amount of information which the student may wish (or may not wish) to

disclose concerning the psychiatric disability.

• In the “Keeping” phase efforts are made to continue to support students in enrollment

and in academic success.The practitioner needs to provide the teaching of special skillswhich the student might need to pursue the programme. Coordination also applies tothose facets of academic life with which the students might encounter some difficulties.

Experience has shown that the need for greater support arises during stressful periodssuch as examinations.

All in all, the relationship established between the practitioner and the participant (stu-dent) is a crucial factor. It has to be egalitarian, continuous and very flexible.

As with other successful rehabilitation programmes, the outcome has an impact on the per-son’s illness. There tend to be fewer rehospitalizations and a need for lower doses of med-ication (occasionally the need for medication may disappear) for persons involved in the

programme.



38/77

5.4.4 Overcoming obstacles linked to prejudice and stigma

Stigma is basically an attitude that aimsat marginalizing and ostracizing some-one because that person has a mentalhealth problem. While the stigma can bequite overt, it tends nowadays to bemore subtle. For instance, a person may find it very difficult to obtain appropri-ate lodging or to join a social club. Itmay include fears of violent behaviouron the part of the person with the mental health problems.

While violence attributable to mental illness exists, it is very low when compared

to other forms of violence. The risk of violence is much greater when severe men-tal illness is associated with alcoholism and drug abuse (64 ) and when there is apast history of violent behaviour.

In its most advanced forms, stigma leads to exclusion of the person from severalspheres of social functioning. Stigma may have disastrous consequences when aperson with a mental health problem starts believing that he/she deserves to betreated in such a way. Stigma can also manifest itself in the “denial” of the per-son’s competence, ability and potential.

The best way to fight stigma is through appropriate education and information.This may include a public information campaign, courses, conferences, etc. It isimportant to delineate very precisely what component of “general stigma” one

wants to address and to develop a specific plan of action for it.

The mass media often portray persons with mental illness in a most unfavourablelight. It has been shown (65 ) that nearly half of health journalists have seriousmisconceptions concerning mental illness. Codes of ethics should be strength-ened and rigorously applied to eradicate the altogether frequent “sensationalism”

with which the press treats stories involving persons with “alleged” or “real”mental health problems. Since the media play a crucial role in filtering informa-tion that reaches the public, it is obvious that all efforts should be made by men-tal health professionals to work closely with them and to correct themisconceptions which they may harbour.

Recently, advocates in the mental health/illness field have made progress withthe mass media, stirring up interest and controversy at both the international andnational levels. In general, there has been more widespread discussion in the press

and on television regarding the situation of this traditionally overlooked disability group and more in-depth presentations about some of the political and profes-sional issues in this field.

Today, advocates are more successful at working with the press and on theInternet to bring mental health/illness issues both into the mainstream of the


“There is a growing awareness that

disability is not so much an

impairment of the individual as a

product of the environment in which

he or she lives.”

Source: ILO (63).


39/77

disability rights movement and to the attention of the public. At the internationallevel, advocates are combining three themes to attract media coverage: redefiningthe bottom line as a universal human rights issue, subjecting residential institu-tions to worldwide exposure, and building support for community based services

(66 ). Ultimately, this type of advocacy can ameliorate negative myths and stereo-types and, in turn, can impact and influence work opportunities for individuals with mental health problems.

Another important way to fight stigma is to inform the community of “goodpractices” and of programmes that work.

5.4.5 Myths about mental illness and the workplace

The following are major myths and facts

regarding the impact of mental illnesson the workplace (67 ):

• Myth 1: Mental illness is the same as mental retardation.

Facts: These are two distinct disorders. A diagnosis of mental retardation ischiefly characterized by limitation in intellectual functioning as well as difficulties

with certain daily living skills. In contrast, among persons with psychiatric disabil-ities, intellectual functioning varies as it does across the general population.

• Myth 2: Recovery from mental illness is not possible.Facts: Long-term studies have shown that the majority of people with mental ill-nesses show genuine improvement over time and lead stable, productive lives.For many decades mental illness was thought to be permanent and untreatable.People with mental illness were separated from the rest of society through institu-tionalization in mental hospitals. As medications were discovered which helped toalleviate the symptoms of mental illness, there was a gradual evolution towardsthe provision of treatment and rehabilitation services in the community.

• Myth 3: Mentally ill and mentally restored employees (the term denotes whenthe disorder is effectively treated) tend to be second-rate workers.

Facts: Employers who have hired these individuals report that they are higherthan average in attendance and punctuality and as good or better than otheremployees in motivation, quality of work, and job tenure. Studies reported by USNational Institute of Mental Health and National Alliance for the Mentally Illconclude that there are no differences in productivity when compared to otheremployees.

• Myth 4: People with psychiatric disabilities cannot tolerate stress on the job.Facts: This oversimplifies the complex human response to stress. People with a

variety of medical conditions, such as cardiovascular disease, multiple sclerosis,and psychiatric disorders, may find their symptoms exacerbated by high levels of stress. However, t

mental health vs work

Documents